Module 2: Quality Program Implementation

CHW programs can readily fail without proper design and implementation. Without appropriate structure and support, CHWs can face numerous barriers to the successful execution of their duties. For example, in a study conducted in rural KwaZulu-Natal, South Africa, CHWs reported feeling overwhelmed due to the large number of households for which they were responsible, the lack of needed supplies (including pens, bandages, gloves, etc.), and the lack of support from community health facilitators. Moreover, they were dissatisfied with their low stipends and the lack of support from supervisors while they experienced emotional strain, whether as a result of caring for the sick and dying or from helping the poor. The lack of supplies reflects the financial strains on the health system at large and also illustrates the need for health system strengthening. A variety of issues must be considered for quality program implementation.(1)

Based on an analysis of the literature concerning CHW program evaluations, Hermann et al. (2009) delineated eight conditions that a CHW program must fulfill in order to be successful in terms of its quality, sustainability, and scalability. The authors note that a program must meet all eight conditions or risk failure. The first five considerations are basic necessities, and the final three pertain to the program’s scalability. The following list is adapted from Hermann et al. (2009)(2):

Selection and motivation: CHWs must be members of the community with which they work and must be motivated to help their community. The level of education is less important than these factors. Without trust from the community, CHW turnover is higher.

Initial training: Training should include practical knowledge on local diseases and on communication and counseling skills. All training should be adapted to the roles and tasks that the CHWs will fulfill.

Simple guidelines and standardized protocols: In order to ensure a baseline of quality in all care provided by CHWs, standardized protocols and tools should be used. These protocols should ensure that CHWs do not practice beyond their skills and can appropriately provide the services that they have been trained to deliver.

Supervision, support, and relationship with the formal health services: In order to ensure quality practices, CHWs need to have adequate supervision and supplies from non-governmental organizations (NGOs) or public health organizations and need to participate in refresher training sessions. The Bangladesh Rural Advancement Committee (BRAC) has successfully established a CHW program that provides adequate monitoring to ensure quality of care. The program stipulates that health professionals must not denigrate CHWs and their vital role in providing care for inaccessible populations. In addition, the program states that referrals to the formal health sector must be facilitated.

In a Sneider et al. (2008) study, CHWs were interviewed about their roles. One CHW commented, “We are working so hard, we make sure we do our work perfect but no one sees that. Yes, we are volunteers but we need someone to say thank you for what we are doing. We need to be appreciated, that alone will mean a lot to us.” The lack of recognition by other health care professionals can have a detrimental effect on the morale of CHWs and their level of work satisfaction, which can lead to higher turnover or a breakdown in collaboration between CHWs and the formal health care sector.(3)

Adequate remuneration/career structure: When CHWs are volunteers, turnover is high, and their working hours per week are few. The most successful CHW programs pay their employees since volunteering prevents CHWs from earning money performing other jobs. In addition, evidence suggests that turnover rates decrease if programs present the possibility of career development. While retention of CHWs is low if they are unpaid, it may be difficult for NGOs to provide salaries in the long-term due to limited funding.

The South African CHW Policy of 2004 stipulates that volunteers should not be employed more than a few hours per week without remuneration. In addition, the government set a national level for monthly stipends for full-time CHWs to be R1000 or US$143. These stipends contribute to attracting and retaining CHWs.(4)

Political support and a regulatory framework: National programs must define the limits of the duties of health care professionals and CHWs and must regulate CHW programs through the aforementioned measures.

Alignment with broader health system strengthening: CHWs cannot serve as band-aid solutions to weak health systems, but instead should supplement health systems which are able to provide adequate clinical care, supply of materials, training, evaluation, etc. This is especially important because, as found in the Sneider et al. (2008) study, many CHWs hope to find permanent employment in the formal health sector. CHWs could ultimately contribute to expanding the numbers of health professionals in countries that lack adequate health care coverage for their populations. However, this can only occur if the healthcare system is simultaneously improved and structured in a way that allows for proper training and incorporation of new employees.(5)

Flexibility and Dynamism: CHW programs must adapt to changing needs and expectations. In order to do so, the programs must continuously interact with the formal health system and their society. In the South African health system, Sneider et al. (2008) note that in order to build a sustainable and effective CHW system, “Maintaining an appropriate balance between regulation of the CHW infrastructure and provincial and local flexibility” is necessary.(6)

Having studied CHW programs in Uganda, Namibia, Malawi, Ethiopia, and Brazil, Celletti et al. (2010) compiled a similar list of qualities that are necessary for ensuring CHW program quality, sustainability, and efficacy. The paper concluded that “The findings also show that certain conditions must be observed if CHWs are to contribute to well-functioning and sustainable service delivery. These conditions involve adequate systems integration with significant attention to: political will and commitment; collaborative planning; definition of scope of practice; selection and educational requirements; registration, licensure and certification; recruitment and deployment; adequate and sustainable remuneration; mentoring and supervision including referral system; career path and continuous education; performance evaluation; supply of equipment and commodities.” Added to the eight considerations above is collaborative planning. The authors stated that various organizations including Ministries of Health, Ministries of Education, Ministries of Rural Development, medical councils, nurses associations, non-governmental organizations, and other related international, national, and local organizations must be included in the design and implementation of the program. CHW programs that involve the Ministry of Health are often more successful because of the Ministry’s networking with various stakeholders.(7)

The Importance of CHW Integration into the Formal Healthcare System

Integration of CHWs in Developing Nations

A study conducted in Mozambique concluded that CHWs should be better integrated into the healthcare system in order to avoid problems resulting from a limited vertical approach to care and the heterogeneous coverage of healthcare services. The Ministry of Health and Médecins Sans Frontières (MSF) collaborated to devise a plan to “maximize community participation in the management of a broad range of health problems via a community health team (CHT) [and] provide coverage of the most basic health needs for the target area .” In this system, one CHW serves as a team leader for 10- 15 CHWs who serve approximately 15,000 people. The CHWs meet with local authorities and community leaders to examine strategies used to combat health problems. In addition, each community is given two to three bicycle ambulances to facilitate CHW referrals to clinics and hospitals. T he CHWs are held accountable for their responsibilities and are given support from the community and existing health structures. In addition, primary care nurses work with the CHT to deliver services such as vaccinations and antenatal care. Working within an integrated system, CHWs can provide a broader range of health services and facilitate effective communication between communities and health facilities. The authors conclude that while NGOs can make valuable contributions through technical and financial support and innovation, the Ministry of Health must ultimately be responsible for the coordination and direction of CHW programs in Mozambique in order to develop an integrated, accountable, and expanded system of care.(8)

Ministries of health must advance the development of the entire healthcare system in addition to promoting the integration of CHWs. Hermann et al. (2009) explain that government CHW programs “ seem more attractive than the NGO-based programs for scaling up ART [antiretroviral therapy] and reaching coverage, as the CHWs are already part of the health system's structure, regulatory frameworks exist and career prospects can be created. However, we contend that they run the highest risk of neglecting quality assurance if their scale-up is not aligned with broader health systems strengthening.” If CHW programs are implemented with these criteria, they have the potential to expand health services for individuals without access to adequate care.(9)

Integration of CHWs in the United States

CHW programs in the United States have historically received funding from short-term grants, or have relied on volunteers. Although this small-scale model has resulted in positive health outcomes in a number of communities, many public health officials recommend that the U.S. “implement a national agenda for CHW evaluation research” and standardize CHW training programs and certification requirements.(10) Martinez et al. (2011) suggest that such an expansion of the CHW role in the U.S. may be highly compatible with the Patient Protection and Affordable Care Act. The law emphasizes reducing health care costs while improving health care quality, particularly by using accountable care organizations and patient-centered medical homes, which “stress the importance of interdisciplinary, interprofessional health care teams, the ideal context for integrating CHWs”.(11)

Although it is financially tempting to rely on the efforts of unpaid CHWs, volunteerism can limit CHW programs. Most public health scholars agree that volunteer-based CHW programs are unsustainable, limited by economic and social demands on local volunteers. Jeffrey Sachs explains, in his review of Tina Rosenberg’s book, “Join the Club”, that unpaid CHW programs may be successful initially, but volunteer absenteeism will eventually increase, and morale will decrease with time. Sachs explains that “paid community health workers are necessary for the long haul…the social cure is not self-sufficient; it requires support from the outside”.(12) Martinez et al. (2011) argue that CHW program sustainability will best be achieved by a capitated payment system, in which health care providers are compensated at a fixed rate for each individual assigned to the provider. However, they note that several states have been successful in expanding CHW programs through Medicaid funding.(13) Regardless of the payment structure that the U.S. adopts, officials should remember lessons learned from CHW efforts in other countries: paying CHWs living wages, offering opportunities for educational advancement, and publicly valuing the role of CHWs. These will facilitate the expansion and acceptance of CHW programs by local communities and medical professionals.(14)

(10) Balcazar, H., Rosenthal, E. L., Brownstein, J.N., Rush, C.H., Matos, S., Hernandez, L. (2011). Community health workers con be a public health force for change in the United States: three actions for a new paradigms. American Journal of Public Health, 101(12): 2199-203.

(11) Martinez, J., Ro, M., Villa, N.W., Powell, W., Knickman, J.R. (2011). Transforming the delivery of care in the post-health reform era: what role will community health workers play? American Journal of Public Health, 101(12):e1-5.

(12) Sachs, Jeffrey, D. 22 May 2011. “Help from the Herd”. The New York Times.

(13) Martinez, J., Ro, M., Villa, N.W., Powell, W., Knickman, J.R. (2011). Transforming the delivery of care in the post-health reform era: what role will community health workers play? American Journal of Public Health, 101(12):e1-5.